JESSE: The first time I was involuntarily placed in a psych ward I was in shock. I hadn't even begun to comprehend what was happening to me. But by the third time I was confined for treatment a question began to form, where did this idea come from? Why is it socially acceptable to encounter people in distress and conclude that locking them in a psychiatric facility is the appropriate response? Who benefits from that?
To better understand the origin and evolution of psychiatry I spoke to David Cohen.
DAVID COHEN: My name is David Cohen and I'm a professor of social welfare, or social work, at the university of California in Los Angeles. I research a number of aspects, I guess, of the mental health system, both practices like the use of medications or the use of involuntary confinement.
And also ideas, the history of ideas in the mental health system, the history of the treatments, interventions, and how professions come and go.
JESSE: In order to trace the origins of involuntary commitment laws I asked David, when did psychiatry first appear in the United States?
DAVID COHEN: In the Western world Psychiatry grew out of what's called the trade in lunacy, or private madhouses. Private madhouses existed in England from about the late 1600s and what they did is they took care of inconvenient, troublesome relatives for wealthy clients.
Let's say you wanted to take your dad's fortune, but your dad was in the way. So you could have a private madhouse take your dad and care for them involuntarily. You paid them and it was acceptable.
And who owned these madhouses, these private small madhouses? They were entrepreneurs, commercial entrepreneurs. Sometimes they could be church officials, they could be just business people, they could be some of them physicians. Bit by bit these small establishment, private, began to go public. They began to turn themselves as States, generally in Western Europe and so forth, kept themselves a bit more busy with social welfare, if you will. They began to fund some of these madhouses, which turn into small public kinds of hospices and hospitals, which had a different connotation than the hospital as we take care of it today. Sort of places of hospitality for increasingly poor people, but still paying clients. Small establishments, five to 30 to 40 people. And the first such institution appeared in the United States, Williamsburg, Virginia, 1770. But at that time you still couldn't talk of Psychiatry as a distinct discipline, not even of mental medicine, you know, late 1700s, it's still madness. Insanity was still some kind of, not an acceptable condition, but something not necessarily thought of as having to do with medicine. Kind of an affliction of the soul, possibly even some sort of blessing, but not really the concern of physicians, just quite yet.
Now, the people who ran these institutions, they were called alienists because they concerned themselves with the management of alienation, madness and sanity. And they began to formalize their management principles. The most famous of those people is Philippe Pinel. He was a French physician, late 1700s, 1790s around right after the French revolution, he begins to popularize what's been called since then moral treatment, which was basically a daily regime of work instruction, exercise to change the behavior of the residents of these institutions. You know, according to the norms of the day.
That is what is happening in the U S around that time too. A few others, Quakers, open an institution too. And in 1844, 13 of those alienists, they form an association. They call it the Association of Medical Superintendents of Institutions for the Insane. 50 years later, that association renames itself, 1893 if you want a date, the American Medical Legal Association. In 1921, it calls itself the American Psychiatric Association.
JESSE: What was the goal of psychiatry when it was formed in the U.S.?
DAVID COHEN: Every person you ask who might know something about that is going to have a different answer, so that's the only preface I can give you to that.
But the way I answer that is, well, the goal was like any nascent profession, it wanted to grow and develop and become prosperous. But what did it need to do in order to do that? You know, mid 1800s, medical men are beginning increasingly to get involved with managing people called mad. Well, first it needed to convince society, or the decision makers, that that issue, madness, that phenomenon, whatever it was was a medical matter. First thing. It had to relabel, redefine madness eventually, or as we call it today, mental illness. Wasn't called mental illness necessarily, but it had to define madness as a disease. Secondly, based on that, it had to convince people that as medical men, they were able to devise the treatments to solve this disease. And then it had to offer to treat this disease by running the asylums.
So if you will, if you consider the early 1900s is the time when psychiatry had to be doing this convincing. That's really when it happens a lot. Is redefining problems, considered moral problems, criminal problems, legal problems, how to live problems, had to redefine them as disease.
In the 1920s, the situation of the population of the insane is different than in the late 1700s. By then you've got large walled asylums, usually on the outskirts of almost every major city in almost every state in the United States. These are housing hundreds of people, no longer 30, 40, homogeneous population. Now you've got a lot of immigration. You've got the industrial revolution that has gone through already Western Europe. It's going through the United States. It's changing norms of conduct and families. It's creating these underclasses in the large cities. There's a lot of stuff that's going on. And so the asylums are now turning slowly into some sort of warehouses. By now they're just, you know, you could be a criminal, you could be abandoned by your family, you could just be senile, you end up in the asylum and you're under lock and key. And you're there for a long time under some supervision. And remember at that time, 1920s, 1930s even, very few individual practitioners. Because there's no voluntary psychiatry. You can't hire professional help to deal with your difficulties in living the way you do it now. This is a different ballgame altogether, very few private practitioners.
But that begins to grow around World War One, 1914, 1920, the men are out, they're gone to war. There were child guidance clinics happening to guide the children. Psychiatry begins to take a more public health approach because first it was not quite distinguished. Neurology people were saying, you know, If you were a private practitioner of neurology, you know, putting people to sleep in these prolonged sleep cures with barbiturates, you were just like throwing water on them, you were playing with their nerves with electrical apparatus because everything was called nerves. So a psychiatrist was barely distinguished from that. So with World War One, they took a more public health approach. It was called at the time mental hygiene. They begin to be more confident because medicine was now a very important profession. It was growing, you know, advances in bacteriology, infectious diseases were being made. So Psychiatry said, Hey, we're part of that too. So we can solve the problems, you know, related to poverty, to alcoholism, to the deteriorating urban life. We're going to take more of a role in that, and [it] helped them to grow as private practitioners.
That's my short answer to what Psychiatry needed to do, or what was its goal.
JESSE: At what point did psychiatry start to focus on a psychoanalytic approach?
DAVID COHEN: Psychoanalysis formally encounters America when Freud, Sigmund Freud, the founder, the inventor of psychoanalysis visits America. Visits Massachusetts. He's invited by Clark University in 1909 and he says, very famous words at the time speaking to his biographer I believe, I've come to bring them the plague. Like they don't know it. They're very excited for me to be there, but they don't know that I am bringing them the plague. He said that himself, you know, it's been interpreted many ways.
He comes in 1909 but the approach really doesn't become prominent until the mid thirties when many Jewish physicians fleeing Austria and Germany are finding haven in the United States in England, mainly in Argentina, for example, many Jewish physicians, including many psychiatrists who were into the psychoanalytic approach and from Germany, which was the leading scientific center of the world. So they were looked at as having some sort of authority and knowledge. They're ambitious people, and that begins to help the spread of psychoanalysis in America.
But the important thing to mention is that while this was happening, the 1930s, that's the biggest growth period of the asylums in America. It's precisely when psychoanalysis starts to get prominent, it's the Great Depression, the asylums are cracking in terms of people being sent there. That's the biggest growth period, is like, 1930 to 1945. Their populations are growing to reach in about 1955, half a million people. So psychoanalysis gets dominant after the war, that's Second World War. You could say 1950 psychoanalysis is at its peak. Everything is psychoanalytic. You know, if you're called on the radio as an expert, you’re into psychoanalysis, if the press is discussing difficulties, it's discussing what your mother did with you or whatever. In other words, that's the school of thought in mental health at that time.
But what I want to say is that all of this existed alongside this huge network of involuntary psychiatry with these half a million people. So psychiatry was a bit like, to use a different expression, a house divided. Meaning separate but equal kind of parts of involuntary and voluntary psychiatry existing in completely separate ways, little connection with each other, and that constituted psychiatry.
JESSE: When did psychiatry start to adopt more of a pharmacological approach?
DAVID COHEN: Some historians are going to see that there's this continuity, that there was always an important pharmacological approach in psychiatry since the 1800s. They talk about the use of hashish, they talk about opium, bromides, and barbiturates in the late 1800s. That's always been there, but everyone kind of agrees that 1952, with the arrival of the neuroleptics, Thorazine was the famous brand name, early 1950s in France, spreads to the U.S. in 1954, 1955. That marks the beginning of what you would call the modern, you know, pharmacological era in psychiatry.
Early fifties, people quibble on that. There's other dates, like when LSD was discovered in 1938 by Albert Hoffman. People bring that date as that's when it really began. Other people talk of the discovery of lithium to calm agitated people, 1949 or so. But almost everyone says, whatever else happened, early fifties with the arrival of the antipsychotic neuroleptics in the psychiatric hospital, that kind of changed the whole game.
And by the sixties you have valium, the benzodiazepines, the tranquilizers, and the stimulants, the amphetamine, like Benzedrine. Those are prescribed enormously to the adult population in the United States. That's the sixties, 10 years later. By the late eighties with the arrival of Prozac and the promotion of the chemical imbalance metaphor widely by the drug companies and everything, then you could say the pharmacological approach is now super dominant. That means whatever the problem, whatever the age group, whatever the situation, prescribe a drug first. Psychoanalysis used to be dominant in the fifties. By the late eighties, the pharmacological approach is totally dominant. By the nineties, expanding with Ritalin, you know, confirming that the market has now expanded completely to include children, which was, that's a new thing. I guess you could say, that's the height of the pharmacological approach in world psychiatry.
JESSE: What legal or social mechanisms separate the pharmaceutical industry from the institution of psychiatry?
DAVID COHEN: Let me first outline what does not separate psychiatry from the pharmaceutical industry. Because about 10 years ago I called psychiatry a satellite branch of the pharmaceutical industry to indicate that virtually every line of thinking and practice in that profession, in psychiatry, came from the industry.
I mean, the industry spends billions of dollars every year to educate psychiatry, their key opinion leaders. It funds much psychiatric research. It visits as many individual psychiatrists as it can and gives them new drugs to persuade them, to give those to their patients, to prescribe them later on for as long as they can. And it draws in psychiatrists by paying them good money to become consultants. And that's just some of what it does. This occurs in all medical disciplines, by the way, not just psychiatry. So that tells you that, my God, there's a lot of common shared stuff.
So what separates them? Well, some codes enacted by some universities or hospitals to identify whether a researcher is getting rewarded by a drug manufacturer while, you know, at the same time that that researcher is supposed to objectively evaluate the manufacturer's drugs, let's say. So are you getting money from the manufacturer? Like, are you double dipping here? You know, you're supposed to represent objectively what is the matter with that product or not, and then the manufacturer is paying you? So there's some codes of ethics and stuff in some institutions. That's one mechanism.
There is a federal law. There's something called a Physician Sunshine Act that was enacted during the Obama administration, 2010, 2011. It mandates any physician to report any gift over a hundred dollars annually that goes into a database and every quarter or so the database publishes the names of these physicians and how much they're getting from which industry.
And then also you've got things like rules in most medical journals today that require the authors of the articles to identify any, you know, disclose any commercial relationships that might conflict with their, you know, expected role as a truth teller or a scientist. I've mentioned three things here that I can think of, you know, easily, there may be more. But none of the ones I've mentioned is considered very effective.
It all depends on the willingness of journalists or academics to study the databases and analyze and report the findings. There's no, you know, law or super-duper mechanism that is really keeping a distinction or a separation, a firewall, between the professions and not just psychiatry. Psychology may have been more stricter in quickly identifying some of the problems and erecting firewalls. Other professions, all the so-called medical and allied professions, are vulnerable, very vulnerable.
And certainly the public is, with direct to consumer ads of drugs and other products. Everyone's very vulnerable because a lot of money goes in every year to persuade us to like the pharmaceutical industry and appreciate what it does for us.
JESSE: So there's a lot of influences affecting psychiatrists, even how they learn to practice. Is there anything that can stop the opinion of a professional from detaining someone for evaluation?
DAVID COHEN: Okay. So you're bringing up, when you mentioned detaining, you're bringing up the issue of involuntary care, or involuntary treatment, or interventions, or as I call it in, in a study that I have recently been working on, involuntary psychiatric detention.
So that's a particular procedure run or regulated if you will, by state laws. So each state has its own law to say, you could do that to someone, if you consider them dangerous as a result of mental illness. So it calls upon physicians or mental health professionals to evaluate the person, say, and to pronounce a judgment. Do you think they're likely to harm themselves or others as a result of mental illness? Are they dangerous as a result of mental illness?
I keep repeating that because it's important, because a lot of people are dangerous. A lot of people are extremely dangerous, but if it's not as a result of mental illness, as determined by a professional, then they, no one really cares about it. They could be a spectacle, but if it's as a result of mental illness, we could detain you and see what we could do about it. And that's commitment. It's called involuntary civil commitment.
And you're asking me if someone's in that situation, what can, you know, go against the opinion, if you will, what can limit the opinion of a professional from detaining you?
I would say that the presence of a friend or a relative who says that, you, if you're the person who's possibly subject to this detention, if the say that you got a place to go where you're going to be safe for a couple of days. That in my view would be decisive. That might make the professional change their mind.
Why? Because involuntary psychiatric detention is supposed to be allowable only if no less restrictive alternative is available. No less restrictive alternative. Now how the professional looks for such an alternative or evaluates whether it's even available or exists or appropriate, is unknown. We don't know.
We just know that in the jurisprudence, the courts, if you will, when people have contested or tried to reject these sorts of orders. The courts say it's gotta be a kind of, really a last recourse. You've got to make sure that there's no other place where the person could go, that's less restrictive than being held in a hospital, in a locked room, being stripped searched and all this stuff that goes with that.
So that if a trusted, I would say that a sensible friend saying you got a place to go, you'll be calmer and fairly safe there for a couple of days. That would be very compelling. A hospital would really have to find a darn good argument to hold you if that situation occurs. That's what I would say.
JESSE: In episode one I discussed the experience of being involuntarily committed to a psych ward for evaluation. I have spent years obsessing over this, trying to see it from every possible perspective. Trying to figure out what could I have done differently? How could I have stopped that from happening? I was privileged enough to eventually get to face Dr. Bynum, the psychologist who committed me, in court. It took eight years, 13 hours of deposition, and two rounds of approval from a state tribunal but I got a chance to seek answers through a civil trial. On day one of the trial, the judge acknowledged that he was employed part-time by the same university where I was section 12’d and that he would never allow a verdict in my favor. When Dr. Bynum took the stand, he acknowledged that he didn't think I was suicidal. He acknowledged that he had spoken to both of my parents and was aware that my brother Tom was there at health services waiting to give me a ride to a hospital. Dr. Bynum said that at some point in the day he saw me laughing, and that was such a contrast from earlier in the day when he had seen me crying that I was determined to have a labile mood. And that behavior, one brother using really bad jokes to try and comfort the other during a moment of distress, that behavior meant that we couldn't be trusted.
So instead, Dr. Bynum had me strapped into a gurney by EMTs and wheeled into a locked psychiatric facility for evaluation.
When David says that in the U S a person can only be committed if there's no less restrictive alternative. Legally he's right. But sometimes, no matter how many family members are involved in the process, the opinion of someone with a few letters after their name is all it takes to physically restrain and detain a person in distress.
To better understand this type of authority and why we as a culture don't talk about it more, I asked David what the proposed or assumed social benefits of involuntary care might be?
DAVID COHEN: Let me give you first my answer, and then tell you what might be the assumed answer, the more mainstream answer. My answer may be a little different, but involuntary psychiatric commitment lets people know that there's a system that's going to deal with people who will break down in families and schools and workplaces, or even in some of the extreme environments where people can live, like the street.
In other words, it's a signal. It’s a strong signal but it's a quiet signal because it's not discussed that often, that the society will try to preserve the integrity of the social institutions that it prizes, that it considers basic, like the family. And it's going to do that by seizing and holding away the individual who, without breaking the law, remember civil commitment is for people who do not break the law by definition, they break the law, you arrest them, you charge them with a crime.
So we're talking about presumably innocent people. So they're going to be held. They're going to be kept away. Because they appear to threaten that prized institution and they're not easily persuaded to stop. So I would guess that most people, even without thinking about it too explicitly, are very grateful to know that psychiatry, aided, sanctioned by the state, exists to do that. That's a huge benefit, which I don't often hear discussed. Just knowing that these people over there will come, they'll take that person away and they have a set of institutions where they will do what they need to do.
Now it's justified by us saying, or many of us believing that well, I guess that's because the person is ill and we're going to give it to them because they'll treat that, they'll treat the illness. That's another story altogether, but that’s to me the main social benefit. It's a glue that keeps the social groups together by coercing when persuasion and, you know, bribery, seduction, leverage, fail.
JESSE: Uhhh…
DAVID COHEN: Yeah, there are other things you could say. I mean, you can say, Oh, well it might save some lives. But that itself is not known overall because there's evidence that it might not save lives really. Or you could say, the benefit is that we have more order. There's more order in the society, if you will.
Those, I'm just taking for granted, that people might think that, assume that. So I'm not getting into that, but you could say that, you know, the state is exercising its power to keep order in the streets, for example. So commitment might, you know, indirectly contribute to that. It will just make people have some solution to what is going on in their family with either their father, or mother, or their child.
That's very tough. How do you expulse a child from your home? An adult child. How do you do that? It's almost impossible because they're your child. This is not a business, it's a family. So these problems that occur in families are extremely difficult, but there are some people who will come and take this away so you don't have to feel or be pointed like you expulsed your children because they threatened you, or they broke the window. It's illness that's being taken care of.
JESSE: One of the things I'm still trying to comprehend is that, uh, if you're going in for surgery, you can often be told the risks of mortality, that you need to sign this waiver. You need to understand, here are the risks, but we're doing this because we have evidence that you need it and this surgery will help you get better. I can't, or haven't been able to, find anyone providing evidence that involuntary care is proven to help people get better. I've heard some stories. I've heard stories where people believe they got better. I've heard stories where people got through it and it wasn't a big deal. And I've heard stories where it was pervasively traumatic, but I can't find any evidence to back this up.
DAVID COHEN: So, to back this up, we need to study what happens to people. You know, maybe, what are the pathways that lead them into involuntary care let's say, as you might call it, and what happens to them during? And then what happens after they leave?
That is not studied a lot.
It's just not studied very much for different reasons. If on the one hand, I can tell you authoritatively, because I've just completed a large study on what is publicly available as data on commitment in the United States, every state we went through. And I can just tell you, if there's not even some seriously, or somewhat accurate estimates of just the number of people that are committed, then just imagine, you think we're going to have very detailed study on exactly what happens to them when they're committed and afterwards? Not really.
But we do have studies that follow up people after they're released from hospitalization in psychiatry without too much attention to legal status, that is, just people who are hospitalized. And exactly what is the proportion of people who are in a psychiatric hospital who would consider that they were forced there by other people? It's hard to estimate really. Some people make the argument that most psychiatric hospitalizations are involuntary, and not just like in an existential sense that, Oh, you don't really have a choice, it was the last place to go, but that there's a lot of pressure to enter in and to stay without it ever being formally registered. It might even break the law. But it just happens because we tolerate it.
And so there are studies that follow what happens to people when they are hospitalized and leave. And one of the constants of this is the rate of suicide is really highest in the entire population for people who leave hospital. That is, for people within the month and the year after a psychiatric hospitalization, the rate of suicide is hundreds of times higher than it is in the general population.
So some people say, well, maybe the people were very suicidal to begin with, that's why they're committing suicide after they leave hospital. But one thing you can say is, well, possibly that could be true, but something else that's probably true is, it doesn't look like the stay in the hospital made any difference.
That's a troubling conclusion, but I haven't seen that seriously studied with attention to legal status, with a good confirmation that the hospitalization was involuntary and then a follow-up. I haven't seen that studied. There are pieces of that data in a few larger studies, but I haven't seen any researcher look at that single-mindedly. It's a very important issue because commitment is the major form of a response to a person's kind of, you know, breakdown, if you will. And if we don't really know what it does, and in fact if it exacerbates, let's say suicide, the threat of danger to yourself, main reason why people get committed from a few States that release data on that.
We know that possibly two thirds of people get committed because they make threats of killing themselves. So what exactly happens when we respond by committing them, if we do? It's really important to know. It is very important to know, but we don't have much data on that.
JESSE: In order to better understand what research on inpatient psychiatric hospitalizations does exist, I asked David about his recently published research into rates of psychiatric detention in the U S.
DAVID COHEN: What we did in the study with my doctoral student Gi Lee and myself, we just tried to look for counts released by States. It is the lowest level scientific task you could say, it's just to count, how much, how many, but it was the most complicated study that I've ever done in my entire 35 year career as a researcher. This was the hardest study I've ever done. Just to count how many people are committed.
I was familiar with counts that Florida releases annually over the last several years, California releases those counts. I was familiar with those and they tell you, in this year, this fiscal year or calendar year, that many people got admitted for involuntary psychiatric detention, or involuntary psychiatric evaluation, or so, and California gives you a bit of a time period, they say, you know, we have these under 14 days and then those over 14 days and maybe lasting up to a year or so. They give you some just aggregate counts, breaking down a bit by counties.
Florida does the same just for the emergency ones, they don't tell you for anything longer than three days. But I was familiar with those and we undertook to look see every other state in the union, what were their accounts?
And to make a long story short, we found 25 States with usable counts, but only about six States that had fairly detailed counts. Like how many people, their ages and genders or sexes. Were they held for a short time? No state, not one state gave the duration of the commitment, not a single state, except Vermont gave some average duration of longer-term stays, which were about 35 to 48 days on average.
But no other state gave you any sense of, are people held for emergency, who are held under three days? Is it two hours or is it 72 hours? You have no idea. Which is baffling when you consider the electronic monitoring today in electronic medical records that no one even gives you the duration. You just can't tell.
So we counted that. And it's the first study in about 40 years, that actually has such a large sample of States and is able to come up with some reasonable estimate, but not a valid estimate because the counts were incomplete. They were not well-defined.
Some States clearly defined what they released, and then when you asked them a little later, they said, by the way, we didn't count these other 75 institutions, which had another 18,000 people that are not in the total that we released. You know, so in other words, it's almost like anything goes. You can't quite tell. Most States, it's just, the counts are embedded in the general court statistics, just like some numbers, some column or so that doesn't give too much definition, no commentary. But a few States; Massachusetts, Colorado, Florida, California, Virginia, Vermont, released detailed reports with lots of data.
JESSE: In episode one, we discussed Massachusetts general hospital versus CR, a case that attempted to address an undefined section in commitment law that allowed for a person to potentially be held for an indefinite period of time in an ER, before they ever even reached a psychiatric facility. I asked David, if he had found any data that might indicate how long people in situations like this are held in ERs?
DAVID COHEN: You’d never see that case, it would never stand out. Never. There's no way that you could see that level of detail, like I said, no state, zero, indicates in any way that is publicly available how long a person is held. Some have something they call, Virginia, temporary detention orders I believe, or temporary custody orders. They're defined as being two hours in the law, but you have no clue what it means because they sound exactly like the other sort of detention that they also give you a graph about, that's for 48 hours, and the graphs look almost identical. So you can't tell, you can't tell if they move from one to the other or they just count one because it's shorter but the one that really lasts is the longer one. There's no way to tell.
And you know what it reflects? As I think about it like this, society is somewhat ambivalent about doing this. In other words, we're ambivalent about forcing care. We do it, but it doesn't mean we enjoy doing it, or we like it. And people have mixed feelings on this. Even opponents, people who strongly oppose involuntary commitment, have mixed feelings on the subject. And proponents too. And I believe that that ambivalence is reflected in the data. The data is so vague. It's almost like they don't want to tell you, you know. The data speaks and tells us no one wants to know about this, 'cause it's painful. It's almost, like, taboo.
JESSE: As we look further into involuntary care are there any areas that often get overlooked that we should pay attention to?
DAVID COHEN: Every single area. Every step of the process. What is the decision made and why? When Police decide to bring someone to the emergency room. During the assessment, how is that decided? How are less restrictive alternatives searched for looked for, or evaluated if done? What are area level factors? What are neighborhood factors that might contribute to the rate of involuntary detention in two States that are neighbors or something, or in one state and different counties?
I could go on for hours and just identify, every single aspect of the involuntary detention and commitment process requires light. Just shed at least a little light on it. Every single area.
JESSE: I spent the first 19 years of my life, never giving a thought to involuntary commitment. I never wondered why this practice is socially acceptable.
I never questioned who these laws are designed to help. I never thought about any of that until it happened to me. And now, no matter how much research I do, no matter how many people I interview, my voice will always be overcast by a shadow of doubt, because I am one of the people that it is socially acceptable to lock away.